Yahwak, Michael NEW YORK STATE DEPARTMENT OF HEALTH �y�o
Vital Records Section : . Burial - Transit Permit
; Name First Middle Last Sex
Michael Leonard Yahwak Male
'f< Date of Death Age If Veteran of U.S. Armed Forces,
,t4 September 5,2015 56 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Glens Falls
Manner of Death
Medical Certifier
Street Address Glens Falls Hospital
Natural Cause n Accident Homicide E Suicide n Undetermined n Pending
Circumstances Investigation
Name Title
;{ Dr Miles,MD
'i Address
", Glens Falls,NY
' Death Certificate Filed District Number Register Number
f City, Town or Village Glens Falls, NY 5601 L( 3
❑Burial Date Cemetery or Crematory
❑Entombment September 8, 2015 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO C Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
N OTransportation Shipment
p by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'i' Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
"'` 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
I
e
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
fs..;
Date Issued g / q f / 5 Registrar of Vital Statistics W
rr" (signature
''; District Number 5 J r Place 6 �s F.O. \1 S I kf
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
� Date of Disposition °f itii(�' Place of Disposition y1,�,,,� tr ,.,
2 (address)
Cl)111
pre (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises `4,rn Ss+✓ f
Z /.(please print)
W Signature A /).--- Title M 1'"n�
(over)
DOH-1555(02/2004)